Consent and Release of Information

For questions or additional information, call (385) 247-0050
All information is submitted through a safe and secure portal and will never be sold, shared or distributed to anyone for any reason.

1Personal Information

2Consent

3Release of Information

Name*
Email*
Phone*

Use and Disclosure of Protected Health Information:
I consent to allow Utah Doctors At Home to use and disclose my Protected Health Information to carry out medical treatment, payment and healthcare operations.

Authorization for Insurance Payment:
I authorize Utah Doctors At Home to provide medical information to my insurance carrier and I authorize payment of insurance benefits to the Utah Doctors At Home for services provided to me. I agree to pay all deductibles, co-pays, and co-insurances.

Authorization to leave voice mail or email:
I authorize Utah Doctors At Home to leave messages by voice or email reminding me of scheduled medical appointments and other medical services for myself and/or my family members.

Care Continuum:
By signing this form, I am choosing to become a patient of the Utah Doctors At Home and Inspiration Home Health/Hospice Care Continuum. By structuring the program this way, it maintains the integrity and viability of a home care model. This provides a more efficient and seamless interaction for my medical needs. I agree and choose to elect Utah Doctors At Home services for any of my primary care needs, I agree and choose to elect Inspiration Home Health or Hospice for any of my home health and hospice related needs.

Consent for treatment by a Nurse Practitioner:
I agree to be treated by a Nurse Practitioner, a healthcare professional licensed in Utah.

By signing this form, I am consenting to Utah Doctors At Home’s use and disclosure of my protected health information as detailed above. However, I may give notice to restrict the use of such information and revoke my consent in writing. I understand that I have the right to review the Notice of Privacy Practices for a more complete description of such uses and disclosures prior to signing this consent.
Signature of Responsible Party:*
Relationship:*
Name of Responsible Party:*
Date:*
MM slash DD slash YYYY

I,
Name*
DOB*
MM slash DD slash YYYY
hereby authorize and request for:
(please list providers/specialists you’ve seen in the last 18 months)
Please list providers/specialists you’ve seen in the last 18 months
Provider Phone Address
To release all medical records in your possession, concerning my illness and/or treatment during the past 2 (two) years from this request to the below named.

Utah Doctors At Home
434 West Ascension Way, Suite 225
Murray, UT 84123
Secure Fax: 888-990-1557
Secure Email: info@amg-homedoctor.com
Signature of Responsible Party:*
Relationship:*
Name of Responsible Party:*
Date:*
MM slash DD slash YYYY
Who may we share your protected health information with?
** If an individual is not listed, we will not release any information about you. **
Who may we share your protected health information with? ** If an individual is not listed, we will not release any information about you. ***
Name: Relation: Phone Number:
Phone
This field is for validation purposes and should be left unchanged.

Consent and Release of Information

SCHEDULE YOUR NO-OBLIGATION IN-HOME MEDICAL ASSESSMENT.

Fill out the form below to schedule a call with one of our medical providers.

Provider	Phone	Address

Name:	Relation:	Phone Number: